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    <div id="content">
        <h1>
            Anticoagulant monitoring</h1>
        <h5 class="updated">
            Last updated: Thursday, 28, October, 2010</h5>
        <table cellpadding="0" cellspacing="0" class="two-column-process">
            <thead>
                <tr>
                    <th>
                        Key Information</th>
                    <th class="description">
                        Appropriate Tests</th>
                </tr>
            </thead>
            <tr class="odd">
                <td class="first">
                </td>
                <td class="second">
                    <p>
                        See also&nbsp;<a 
                            href="http://www.rcpamanual.edu.au/index.php?option=com_clinical&amp;task=show_clinical&amp;id=742&amp;Itemid=27" 
                            target="_blank">Thrombolytic therapy</a>.</p>
                </td>
            </tr>
            <tr>
                <td class="first">
                    <p>
                        <strong>Heparin (standard, unfractionated)</strong></p>
                </td>
                <td class="second">
                </td>
            </tr>
            <tr class="odd">
                <td class="first">
                    <p>
                        Prior to commencing therapy</p>
                </td>
                <td class="second">
                    <p>
                        <b>FBC, platelet count; baseline APTT, INR</b> if patient on warfarin; <b>PT</b> 
                        if warfarin treatment planned.</p>
                </td>
            </tr>
            <tr>
                <td class="first">
                    <p>
                        During therapy&nbsp;</p>
                </td>
                <td class="second">
                    <p>
                        <b>Platelet counts</b> are recommended on day 5 post commencement of therapy.</p>
                </td>
            </tr>
            <tr class="odd">
                <td class="first">
                    <ul>
                        <li>Continuous IV infusion&nbsp;</li>
                    </ul>
                </td>
                <td class="second">
                    <p>
                        <b>APTT</b>; check therapeutic interval with laboratory. In the first 24 hours, 
                        frequent assessment may be required, but the APTT should not be performed &lt;4 
                        hours after any change in dose. Subsequently, a daily APTT usually suffices if 
                        within the therapeutic range.</p>
                </td>
            </tr>
            <tr>
                <td class="first">
                    <ul>
                        <li>Intermittent IV injection&nbsp;</li>
                    </ul>
                </td>
                <td class="second">
                    <p>
                        Monitoring not of value.</p>
                </td>
            </tr>
            <tr class="odd">
                <td class="first">
                    <ul>
                        <li>Prophylactic SC injection (low dose heparin)&nbsp;</li>
                    </ul>
                </td>
                <td class="second">
                    <p>
                        Monitoring not of value.</p>
                </td>
            </tr>
            <tr>
                <td class="first">
                    <p>
                        If bleeding occurs&nbsp;</p>
                </td>
                <td class="second">
                    <p>
                        <b>APTT; FBC, platelet count.</b> Check other medications with patient and/or 
                        from records. Concomitant aspirin or other NSAID increase the risk of bleeding; 
                        their effect on platelet function is predictable and testing is not indicated. 
                        The possibility of a pre-existent acquired or inherited bleeding disorder should 
                        also be considered.</p>
                </td>
            </tr>
            <tr class="odd">
                <td class="first">
                    <p>
                        If progression of thrombosis, or thrombosis in other site(s), causes include:</p>
                </td>
                <td class="second">
                </td>
            </tr>
            <tr>
                <td class="first">
                    <ul>
                        <li>Inadequate anticoagulation&nbsp;</li>
                    </ul>
                </td>
                <td class="second">
                    <p>
                        <b>APTT</b></p>
                </td>
            </tr>
            <tr class="odd">
                <td class="first">
                    <ul>
                        <li>Heparin-induced thrombocytopenia (HIT type II)</li>
                    </ul>
                </td>
                <td class="second">
                    <p>
                        <b>FBC, platelet count; heparin-dependent platelet antibodies</b> if significant 
                        thrombocytopenia is documented and/or significant reduction in platelet count 
                        from baseline level.</p>
                </td>
            </tr>
            <tr>
                <td class="first">
                    <ul>
                        <li>Antithrombin deficiency&nbsp;</li>
                    </ul>
                </td>
                <td class="second">
                    <p>
                        <b>Antithrombin assay:</b> ideally should be deferred until heparin has been 
                        ceased, since heparin will reduce the measured level. See under
                        <a href="http://www.rcpamanual.edu.au/index.php?option=com_clinical&amp;task=show_clinical&amp;id=537&amp;Itemid=27" 
                            target="_blank">Thrombosis</a> - venous.</p>
                </td>
            </tr>
            <tr class="odd">
                <td class="first">
                    <p>
                        <strong>Low molecular weight heparin (LMWH) and heparinoids</strong>&nbsp;</p>
                </td>
                <td class="second">
                    <p>
                        The standard dose protocol is based on body weight; monitoring is not usually 
                        required except in renal failure or other high risk bleeding situations. 
                        Heparin-induced thrombocytopenia is less common than with standard, 
                        unfractionated heparin, but may occur: see above.</p>
                </td>
            </tr>
            <tr>
                <td class="first">
                    <p>
                        Prophylactic SC injection&nbsp;</p>
                </td>
                <td class="second">
                    <p>
                        Monitoring is not required</p>
                </td>
            </tr>
            <tr class="odd">
                <td class="first">
                    <p>
                        <strong>Oral anticoagulants</strong>&nbsp;</p>
                </td>
                <td class="second">
                    <p>
                        <b>INR.</b></p>
                </td>
            </tr>
            <tr>
                <td class="first">
                    <p>
                        Warfarin (Marevan/Coumadin)</p>
                </td>
                <td class="second">
                </td>
            </tr>
            <tr class="odd">
                <td class="first">
                    <p>
                        If bleeding occurs, causes include:</p>
                </td>
                <td class="second">
                </td>
            </tr>
            <tr>
                <td class="first">
                    <ul>
                        <li>Excessive anticoagulation</li>
                    </ul>
                </td>
                <td class="second">
                    <p>
                        Bleeding risk and INR level.</p>
                </td>
            </tr>
            <tr class="odd">
                <td class="first">
                    <ul>
                        <li>Alcohol</li>
                    </ul>
                </td>
                <td class="second">
                </td>
            </tr>
            <tr>
                <td class="first">
                    <ul>
                        <li>Change in diet</li>
                    </ul>
                </td>
                <td class="second">
                </td>
            </tr>
            <tr class="odd">
                <td class="first">
                    <ul>
                        <li>Intercurrent illness</li>
                    </ul>
                </td>
                <td class="second">
                </td>
            </tr>
            <tr>
                <td class="first">
                    <ul>
                        <li>Cardiac failure</li>
                    </ul>
                </td>
                <td class="second">
                </td>
            </tr>
            <tr class="odd">
                <td class="first">
                    <ul>
                        <li><DIARRHOEA< li></li>
                    </ul>
                </td>
                <td class="second">
                </td>
            </tr>
            <tr>
                <td class="first">
                    <ul>
                        <li>Other drugs,&nbsp;especially</li>
                    </ul>
                </td>
                <td class="second">
                    <p>
                        Consult pathologist/pharmacist about drug interactions; consider possibility of 
                        recent change in dose, introduction of new, or non-prescribed, medications, 
                        herbal and/or dietary supplements.</p>
                </td>
            </tr>
            <tr class="odd">
                <td class="first">
                    <ul>
                        <li>
                            <ul>
                                <li>Analgesics</li>
                            </ul>
                        </li>
                    </ul>
                </td>
                <td class="second">
                </td>
            </tr>
            <tr>
                <td class="first">
                    <ul>
                        <li>
                            <ul>
                                <li>Antibiotics</li>
                            </ul>
                        </li>
                    </ul>
                </td>
                <td class="second">
                </td>
            </tr>
            <tr class="odd">
                <td class="first">
                    <ul>
                        <li>
                            <ul>
                                <li>Aspirin, other NSAID&nbsp;</li>
                            </ul>
                        </li>
                    </ul>
                </td>
                <td class="second">
                    <p>
                        Predictable effect on platelet function; bleeding time does not predict the risk 
                        of bleeding and is not indicated.</p>
                </td>
            </tr>
            <tr>
                <td class="first">
                    <ul>
                        <li>Dose error</li>
                    </ul>
                </td>
                <td class="second">
                </td>
            </tr>
            <tr class="odd-last">
                <td class="first">
                    <ul>
                        <li>Concomitant bleeding disorder</li>
                    </ul>
                </td>
                <td class="second">
                    <p>
                        See&nbsp;<a 
                            href="http://www.rcpamanual.edu.au/index.php?option=com_clinical&amp;task=show_clinical&amp;id=82&amp;Itemid=27" 
                            target="_blank">Bleeding disorders</a>.</p>
                </td>
            </tr>
        </table>
    </div>
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            <h2>
                Glossary Terms</h2>
            <div>
                <h4>
                    APTT :</h4>
                <p>
                    Activated partial thromboplastin time</p>
                <h4>
                    FBC :</h4>
                <p>
                    Full blood count , full blood examination, complete blood count</p>
                <h4>
                    HIT :</h4>
                <p>
                    Heparin-induced thrombocytopenia</p>
                <h4>
                    INR :</h4>
                <p>
                    International normalised ratio</p>
                <h4>
                    IV :</h4>
                <p>
                    Intravenous</p>
                <h4>
                    NSAID :</h4>
                <p>
                    Nonsteroidal anti-inflammatory drugs</p>
            </div>
        </div>
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        <p id="thanks">
            The RCPA wishes to acknowledge the Australian Government Department of Health 
            and Ageing for their generous support of the RCPA Manual.<br />
            ISSN 1449-8219</p>
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